3D Mammograms May Catch More Early Stage Breast Cancer
New 3D mammograms can improve early detection of invasive breast cancers. But this technology, known as tomosynthesis, also has some drawbacks.
By Jessica Firger
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WEDNESDAY, Jan. 30, 2013 —When Waltraud Ross relocated from Tucson to Phoenix last year, the 51-year-old sought a new medical facility she could visit for her annual mammogram and other routine tests. She was happy to find John C. Lincoln Hospital, because it boasted cutting-edge technology and the facility was close to her office. The day Ross showed up for her mammogram, the radiologist told her she would have both a regular digital mammogram and a more detailed type, which is standard protocol at the hospital for all women who come in for breast cancer screening.
What Ross didn't know was this new technology — called a three-dimensional mammogram or tomosynthesis — would save her life. She had no family history of breast cancer and had faithfully gone for these breast cancer screenings since turning 40, which is the recommended age to begin screening mammograms based on guidelines outlined by the U.S. Preventive Task Force. In that time, her tests had always been normal. So when her doctor informed her that the tomosynthesis results identified a 2-centimeter mass in her right breast, she was both devastated and surprised.
Tomosythesis is the latest advancement in breast cancer screening technology. It became available in Europe and other countries in 2008 and in the United States in 2011. The first large-scale trial on tomosynthesis — conducted in Oslo, Norway, and partially funded by Hologic, Inc., the only company that manufactures the technology in the United States — found that the 3D imaging device increased the invasive breast cancer detection rate by as much as 40 percent. The study, which was recently published in the journal Radiologyand was based on a sample of 12,631 women ages 50 to 69 years old, also found that tomosynthesis improved detection of both invasive and noninvasive breast cancers by 27 percent, and reduced the rate of false positive mammograms by 15 percent.
An Early Diagnosis and Quick Treatment
Shortly after learning that she had breast cancer, Ross returned to her doctor for a follow-up mammogram and an ultrasound to verify the results. Her doctors didn't waste any time. They conducted a breast biopsy, and then prescribed six weeks of radiation therapy. The following month around the time she finished chemotherapy, her doctor performed a lumpectomy.
"What I was told was the tumor was so small it would not have appeared on the regular mammogram," says Ross, who works in the accounting department for a health insurance company.
Depending on where she went for her screening and what kind of mammography system the facility used, Ross may not have found out she had cancer until it had progressed.
Mammograms: From Analog to Digital to 3D
Currently, there are three types of mammograms available to patients. The first, analog on film, largely has been replaced by digital detector images that are processed in the same manner as regular digital photography. Both analog and digital mammograms produces 2D images, though analog mammography has mostly fallen out of favor because it provides a less detailed image of breast tissue. An Irish study published in 2009 compared the accuracy of digital and analog mammography and found cancer detection rates were 6.3 for digital and 5.2 for analog per 1,000 patients.
Tomosynthesis, which adds only a few additional seconds to the standard mammogram testing procedure, provides doctors with a 3D picture. A high-powered X-ray takes multiple images and the result is a series of photos that allow a doctor to view breast tissue layer by layer, rather than in a single superimposed image.
In order to capture a full image of breast tissue, the mammography machine flattens — or compresses — the breast before taking a picture. The average breast compression is 6 to 7 centimeters wide. Digital mammography produces a single image of the compression, whereas tomosynthesis parses out the images of breast tissue by millimeters, so one digital image becomes six or seven, says Linda Greer, MD, a radiologist at John C. Lincoln Breast Health and Research Center, where Ross received treatment.
"If we're catching things earlier, we can cut down on people who need chemo and mastectomies," says Dr. Greer, who began practicing radiology in 1993 and has used all three types of diagnostic imaging at different points in her career. She adds that callbacks for follow-up mammograms have gone down 40 percent since the hospital installed the 3D technology since April 2011. "We were shocked by how many things were not seen by the very routine mammogram. And we got scared about what we were missing for so many years," says Greer.
3D mammography is especially useful for screening women with dense breasts, say the Oslo study researchers. As a woman ages, her breast tissue becomes fattier and irregular cells are easier to see in a 3D picture. According to Are You Dense, a breast cancer advocacy organization, more than 65 percent of premenopausal women and 25 percent of postmenopausal women have dense breast tissue, which makes a tumor difficult to spot because the tumor and healthy tissue both appear as white in the image. A growth in a breast that's less dense shows up grey in a 3D scan.
Improved Early Detection at a Price
Since 2011, tomosynthesis has increasingly made its way into radiology facilities and hospitals throughout the country and is now available in 48 U.S. states. As of last September, Hologic had installed some 300 tomosynthesis systems at medical facilities across the country. By fall 2013, they expect that number to double, say Hologic executives.
However, because tomosynthesis is a relatively new technology in the United States, many insurance companies have yet to extend coverage. Melissa Banks, senior director of global products marketing at Hologic, says many healthcare providers accommodate their patients by billing insurance companies extra for standard digital mammography even though the patient may have had a 3D scan. Other facilities may charge the patient an out-of-pocket fee, from around to 0, she says.
Greer says John C. Lincoln Hospital doesn't charge patients additional fees for tomosynthesis because several staff members have been treated for breast cancer and the hospital is committed to offering its patients the most advance technology.
But Susan Brown, MS, RN, director of community health at the Susan G. Komen Breast Cancer Foundation, isn't convinced there's yet enough evidence to prove tomosynthesis is more effective than digital mammography. "Women should make a decision about using this after a discussion with their healthcare provider and insurance company," she says. "It's important to discuss the test's drawbacks, especially because the technology is still fairly new."
The main drawback is the potential long-term effect on a woman's health. "One of things I understand is it does require a higher exposure to radiation," Brown says, which is a detail that was verified by both the Oslo study researchers and representatives from Hologic. But, Brown adds, "If this technology reduces the callback rate, then perhaps this higher dose of radiation is acceptable."
Still, Ross — who is now cancer-free, on a five-year course of tamoxifen, returns to her doctor for a follow-up mammogram every six months — gives little thought to possible drawbacks."I was pretty lucky because things like that advance pretty fast," she says.
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